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Maharani Sylvia Rindawati; Pembimbing: Helen Andriani; Penguji: Amal Chalik Sjaaf, Pujiyanto, Atika, Siti Ainun Dwiyanti
Abstrak:
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Pemerintah bekerja sama dengan Badan Penyelenggara Jaminan Sosial (BPJS) melalui program Jaminan Kesehatan Nasional (JKN). Rumah sakit bekerjasama dengan BPJS dalam menyelenggarakan pelayanan kesehatan melalui pengajuan klaim, pembayaran atas pelayanan, dan feedback verifikasi dokumen. Berkas klaim yang tidak lengkap dianggap belum layak disebut dengan klaim pending. Klaim pending dapat mengganggu pendapatan dan proses keuangan. Mayoritas pasien yang berobat di RSUD Mampang Prapatan sebanyak 90% merupakan peserta BPJS Kesehatan. Klaim pending di RSUD Mampang Prapatan pada Tahun 2022 mencapai 13.5% rawat inap dan 3.5% rawat jalan dengan tarif pending sebesar Rp1.190.594.300 rawat inap dan Rp331.363.900 rawat jalan. Tujuan penelitian ini adalah untuk menganalisis penyebab klaim pending dan memberikan solusi berupa inovasi dalam mencegah atau mengurangi klaim pending. Penelitian ini merupakan penelitian kualitatif dengan pendekatan studi kasus. Pengumpulan data dilakukan melalui wawancara mendalam, observasi, dan telaah dokumen. Hasil penelitian menunjukkan, jumlah klaim pending bulan Januari - Juli 2023 ditemukan pada unit rawat inap sebanyak 13.3% dan unit rawat jalan sebanyak 2.3%. Total tarif pending sebanyak Rp780.096.800 pada rawat inap dan Rp145.317.100 pada rawat jalan. Klaim pending disebabkan oleh faktor input dan proses. Faktor input penyebab klaim pending disebabkan antara lain faktor man, yaitu belum adanya verifikator internal, pelatihan koding internal, dan belum ada kebijakan serta evaluasi terkait klaim pending. Dari faktor money, rumah sakit belum menerapkan remunerasi dan belum ada reward dan punishment terkait pengisian resume medis yang tepat dan sesuai untuk menjadi dasar penilaian. Dari faktor material, belum ada kebijakan terkait pengisian resume medis elektronik, beberapa staf rumah sakit belum mengetahui syarat berkas pengajuan klaim, dan tanda tangan pengisian resume medis belum digital. Dari faktor metode, PPK dan ICP hanya tersedia beberapa, sosialisasi syarat pengajuan klaim serta review berkala kasus klaim pending belum dilakukan. Sedangkan, dari faktor machine ditemukan terdapat beberapa komputer yang masih lambat saat menggunakan beberapa aplikasi. Penyebab klaim pending dari faktor proses didominasi oleh ketidaklengkapan berkas pendukung dan masalah dalam koding. Pengembangan prototipe melalui metode design thinking dalam SIMRS telah dilakukan terkait proses pengajuan klaim yang terdiri dari pengumpulan berkas, pengisian resume medis, dan koding dengan menambahkan menu berkas digital, koding yang terintegrasi, serta menu attachment prosedur / tindakan serta diagnosis yang terintegrasi antara perawatan pasien dengan resume medis. Saran bagi rumah sakit untuk menggunakan dan mengembangkan usulan prototipe, upaya perbaikan bagi unit casemix, melakukan sosialisasi mengenai syarat berkas klaim kepada unit terkait, sosialisasi syarat pengajuan klaim BPJS Kesehatan sesuai peraturan kementerian kesehatan dan panduan klinis kepada dokter, dan review berkala secara internal kepada dokter mengenai klaim pending.
The government collaborates with Badan Penyelenggara Jaminan Sosial (BPJS) through the National Health Insurance Program. Hospitals collaborate with BPJS in providing health services through submitting claims, payment for services, and document verification. Incomplete claim documents are considered as pending claims. Pending claims can disrupt revenue and financial processes. The majority of patients treated at Mampang Prapatan General Hospital, 90%, are BPJS participants. Pending claims in Mampang Prapatan General Hospital in 2022 reach 13.5% for inpatient care and 3.5% for outpatient care with pending of Rp1.190.594.300 for inpatient and Rp331.363.900 for outpatient. The aim of this research is to analyze the causes of pending claims and provide solutions in the form of innovations in preventing or reducing pending claims. This research is qualitative research with a case study approach. Data collection was carried out through in-depth interviews, observation and document review. The research results show that the number of pending claims in January - July 2023 was found in inpatient units at 13.3% and outpatient units at 2.3%. The total pending rate is IDR 780,096,800 for inpatient care and IDR 145,317,100 for outpatient care. Pending claims are caused by input and process factors. The input factors that cause pending claims include human factors, namely the absence of an internal verifier, internal coding which is not given to staff, and there are no policies and evaluations regarding pending claims. From the money factor, the hospital has not implemented remuneration and there are no rewards and punishments regarding filling out a medical resume correctly and appropriately as a basis for assessment. In terms of material factors, there is no policy regarding filling out electronic medical resumes, some hospital staff do not know the file requirements for submitting claims, and signatures for filling out medical resumes are not yet digital. In terms of method factors, only a few PPK and ICP are available, socialization of claim submission requirements and regular reviews of pending claim cases have not been carried out. Meanwhile, from the machine factor, it was found that several computers were still slow when using several applications. The causes of pending claims from process factors are dominated by incomplete supporting files and problems in coding. Prototype development using the design thinking approach in SIMRS has been done regarding to the claim submission process which consists of collecting files, filling in medical resumes, and coding by adding a digital file menu, integrated coding, and attachment menus in providing procedure and diagnosis integrated with medical resumes. Suggestions for hospital to use and develop the prototype, improve casemix unit, socialize recarding to the requirements in filling claim documents, and periodically held an internal review to doctors regarding to the pending claims
B-2416
Depok : FKM-UI, 2024
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Kurniadji; Pembimbing: Vetty Yulianty Permanasari; Penguji: Ede Surya Darmawan, Puput Oktamianti, Tb. Rachmat Sentika; Jhon Marbun
B-1972
Depok : FKM-UI, 2018
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Tantri Puspa Ditya; Pembimbing: Wiku Bakti Bawono Adisasmito; Penguji: Helen Andriani, Pujiyanto, Eka Ginanjar, Hima Liliani
Abstrak:
Kesehatan adalah salah satu hak dasar setiap warga negara Indonesia dan sistem Jaminan Kesehatan Nasional yang dikelola oleh Badan Penyelenggara Jaminan Sosial (BPJS) merupakan salah satu upaya untuk memenuhi hak tersebut. Pemenuhan jaminan tersebut dilaksanakan berdasarkan berkas klaim yang diajukan oleh pihak rumah sakit berdasarkan pelayanan yang telah diberikan kepada pasien. Data dari RSUP Nasional Dr. Cipto Mangunkusumo (RSCM) menunjukkan terdapat klaim perawatan pasien yang tertunda dengan nilai yang besar pada tahun 2019. Studi ini merupakan penelitian deskriptif analitik yang dilaksanakan untuk mencari akar masalah penundaan pembayaran klaim perawatan pasien usia lanjut, salah satu populasi pasien dengan kontribusi penundaan pembayaran klaim terbesar di RSCM, sebagai upaya menurunkan angka penundaan pembayaran klaim. Menggunakan metode purposive sampling didapat 131 penundaan pembayaran perawatan pasien usia lanjut pada periode Juli - Desember 2019. Pengumpulan data kemungkinan penyebab pending klaim didapat melalui beberapa metode, yaitu observasi, tinjauan pustaka, telaah dokumen, dan wawancara mendalam dengan duabelas informan, khususnya petugas medis dan administrasi yang terlibat dalam manajemen klaim. Validitas data dipertahankan melalui proses triangulasi sumber dan triangulasi metode pengambilan data. Hasil menunjukkan masalah yang menyebabkan terjadinya penundaan pembayaran klaim mencakup kualitas resume medis dan kesalahan dalam proses coding. Akar masalah yang ditemukan adlah kebijakan yang sulit dimengerti oleh pelaksana sehingga salah interpretasi ditambah tidak terkomunikasikan kesulitan di setiap proses, terlebih tidak ada perbedaan penanganan untuk pasien 60 tahun keatas kurang pelatihan dan pelaksanaan supervisi bagi penulis resume medis dan coder, kurangnya staf coder di unit rawat inap, instrumen peninjauan kelengkapan berkas klaim dan proses perbaikannya yang belum dibuat, keterbatasan akses terhadap dokumen standar prosedur operasional proses-proses terkait, dan aplikasi pemantauan proses klaim yang belum dibuat, serta terbatasnya sarana prasarana yang dibutuhkan untuk menyelesaikan proses ini tepat waktu. Dengan demikian, pembuatan sistem IT manajemen klaim sesuai dengan instruksi kerja berdsasarkan regulasi yang dipakai menjadi saran utama diikuti dengan Diklat sosialisasi media informasi perjanjian bersama BPJS
Health is one of the basic rights of every Indonesian citizen and the National Health Insurance system managed by the Social Security Administering Body (BPJS) is an effort to fulfill this right. Fulfillment of this guarantee is carried out based on the claim file submitted by the hospital based on the services provided to patients. Data from the National Hospital Dr. Cipto Mangunkusumo (RSCM) shows that there are claims of delayed patient care with a large value in 2019. This study is an analytical descriptive study carried out to find the root of the problem of delaying claim payment for elderly patients, one of the patient populations with the largest contribution to claim payment delays. at RSCM, in an effort to reduce the number of delays in claim payments. Using the purposive sampling method, 131 delays in payment for elderly patient care were obtained in the period July - December 2019. Data collection on possible causes of pending claims was obtained through several methods, namely observation, literature review, document review, and in-depth interviews with twelve informants, especially medical and administrators involved in claims management. Data validity was maintained through the process of triangulation of sources and triangulation of data collection methods. The results show the problems that lead to delays in claim payments include the quality of the medical resume and errors in the coding process. The root of the problem that was found was a policy that was difficult to understand by the implementer so that it was misinterpreted plus the difficulties in each process were not communicated, lack of training and implementation of supervision for medical resume writers and coders, lack of coder staff in the inpatient unit, a review instrument for the completeness of the claim file and the repair process. that have not been created, limited access to standard documents for operational procedures of related processes, and application of monitoring of claims processes that have not been made, and limited infrastructure needed to complete this process on time. Thus, the creation of a claim management IT system in accordance with work instructions based on the regulations used is the main suggestion followed by staf training , socializing information media, and agreements with BPJS.
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Health is one of the basic rights of every Indonesian citizen and the National Health Insurance system managed by the Social Security Administering Body (BPJS) is an effort to fulfill this right. Fulfillment of this guarantee is carried out based on the claim file submitted by the hospital based on the services provided to patients. Data from the National Hospital Dr. Cipto Mangunkusumo (RSCM) shows that there are claims of delayed patient care with a large value in 2019. This study is an analytical descriptive study carried out to find the root of the problem of delaying claim payment for elderly patients, one of the patient populations with the largest contribution to claim payment delays. at RSCM, in an effort to reduce the number of delays in claim payments. Using the purposive sampling method, 131 delays in payment for elderly patient care were obtained in the period July - December 2019. Data collection on possible causes of pending claims was obtained through several methods, namely observation, literature review, document review, and in-depth interviews with twelve informants, especially medical and administrators involved in claims management. Data validity was maintained through the process of triangulation of sources and triangulation of data collection methods. The results show the problems that lead to delays in claim payments include the quality of the medical resume and errors in the coding process. The root of the problem that was found was a policy that was difficult to understand by the implementer so that it was misinterpreted plus the difficulties in each process were not communicated, lack of training and implementation of supervision for medical resume writers and coders, lack of coder staff in the inpatient unit, a review instrument for the completeness of the claim file and the repair process. that have not been created, limited access to standard documents for operational procedures of related processes, and application of monitoring of claims processes that have not been made, and limited infrastructure needed to complete this process on time. Thus, the creation of a claim management IT system in accordance with work instructions based on the regulations used is the main suggestion followed by staf training , socializing information media, and agreements with BPJS.
B-2171
Depok : FKM-UI, 2021
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Saly Salim Saleh Alatas; Pembimbing: Jaslis Ilyas; Penguji: Budi Hartono, Pujiyanto, Vetty Yulianty Permanasari, Dwi Satrio
Abstrak:
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Pemerintah Indonesia membentuk Jaminan Kesehatan Nasional yang diselenggarakan oleh Badan Penyelenggaran Jaminan Sosial (BPJS) Kesehatan untuk menjamin kesehatan warga negara Indonesia. Rumah Sakit Ummi Bogor adalah rumah sakit yang bekerjasama dengan BPJS kesehatan dan menerima dana pembayaran klaim dari tarif yang sudah ditetapkan BPJS Kesehatan berdasarkan berkas bukti pelayanan yang didapatkan pasien. Ketidaksesuaian hasil verifikasi klaim akan mengakibatkan klaim pending. RS Ummi Bogor merupakan RS tipe C yang sebagian besar pasiennya merupakan pasien BPJS, sehingga adanya klaim pending sangat berpengaruh terhadap cash flow rumah sakit terutama di unit rawat inap. Tujuan penelitian ini adalah untuk menganalisis penyebab klaim pending BPJS Kesehatan di unit rawat inap RS Ummi Bogor. Penelitian ini adalah penelitian kualitatif. Pengumpulan data dilakukan melalui wawancara mendalam dan telaah dokumen. Hasil penelitian menunjukan jumlah klaim pending di unit rawat inap pada bulan Maret sebesar 93 dari total 1412 berkas (6,58%) dengan biaya pending klaim sebesar Rp. 660.261.900. atau 11,37 % dari total biaya klaim layak. Klaim pending disebabkan oleh ketidaklengkapan berkas klaim, ketidaksesuaian resource (pemakaian obat dan indikasi rawat) dengan diagnosa, ketidaksesuaian tindakan medis dengan diagnosa, kesalahan koding, dan ketidaksesuaian pemeriksaan penunjang dengan diagnosa umum.
Indonesian Government established the National Health Insurance organized by Badan Penyelenggaran Jaminan Sosial (BPJS) Kesehatan to guarantee the health of Indonesian citizens. Badan Penyelenggaran Jaminan Sosial Kesehatan cooperates with hospitals to make it happen. Rumah Sakit Ummi Bogor is a hospital that cooperates with BPJS Kesehatan and receives claim payment funds from the rates set by BPJS Kesehatan based on the proof of service obtained by the patient. Inconsistencies in the results of claim verification will result in claims pending. Rumah Sakit Ummi Bogor is a type C hospital where most of the patients are BPJS patients, so that pending claims are very influential to the cash flow hospitals, especially in inpatient units. The purpose of this study is to analyze the causes of BPJS Kesehatan claims pending in the inpatient unit of . Rumah Sakit Ummi Bogor. This research is a qualitative study. Data collection was carried out through in-depth interviews and document review. The results of the study show that the number of claims pendingin the inpatient unit in March twere 93 files out of a total of 1412 (6.58%) with a claim pending fee of Rp. 660,261,900 or 11.37% of the total cost of claims received caused by incomplete claim files, resource discrepancies (use of drugs and indications for treatment) with diagnoses, discrepancies between medical procedures and diagnoses, errors in coding, and incompatibility of investigations with general diagnoses.
B-2359
Depok : FKM-UI, 2023
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Dewi Sri Rachmawati; Pembimbing: Kurnia Sari; Penguji: Adang Bachtiar, Sandi Ilyanto, Rachmat Sentika, Marian Margaretha
B-1927
Depok : FKM UI, 2017
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Anugrah Aulia Ulil Amri; Pembimbing: Atik Nurwahyuni; Penguji: Prastuti Soewondo, Vetty Yulianty Permanasari, Yenny Nariswari Harumansyah, Budi Hartono
Abstrak:
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Penelitian ini menelusuri manajemen klaim Jaminan Kesehatan Nasional (JKN) di RSUD Kebayoran Lama selama 2022, fokus pada klaim pending, verifikasi, dan audit paska klaim. Penyebab utama klaim pending meliputi resume medis yang tidak lengkap (29%), data pendukung klaim yang kurang (24%), dan kesalahan koding (21%). Sementara itu, masalah paska klaim umumnya muncul dari episode layanan yang bermasalah (39%), kesalahan koding (31%), dan resume medis yang tidak lengkap (22%). Permasalahan tersebut berasal dari elemen-elemen terkait dalam sistem manajemen klaim JKN di Rumah Sakit, memerlukan perbaikan internal. Rekomendasi hasil penelitian menitikberatkan pembenahan internal rumah sakit, seperti mengembangkan metode sosialisasi yang lebih efektif, meningkatkan komunikasi dengan pimpinan, mempromosikan ketepatan diagnosis dan tindakan berdasarkan ICD, menciptakan format resume medis baru, dan memantau pengembangan rekam medis elektronik. Disarankan juga penunjukan staf medis fungsional, pelatihan untuk Ketua Komite Medik, dan advokasi untuk alokasi anggaran. Rekomendasi ditujukan kepada Dinas Kesehatan DKI Jakarta untuk meningkatkan koordinasi antar lembaga kesehatan serta memberikan masukan konstruktif kepada pemerintah terkait praktik pemeriksaan paska klaim oleh BPJS Kesehatan yang belum sesuai regulas pemerintah. Studi ini menekankan perlunya penyempurnaan aplikasi BPJS Kesehatan untuk menciptakan mekanisme umpan balik yang lebih efektif dalam menangani masalah klaim JKN.
This study investigates the management of National Health Insurance (Jaminan Kesehatan Nasional - JKN) claims at RSUD Kebayoran Lama Regional Hospital in 2022, focusing on pending claims, verification, and post-claim audits. The primary causes of pending claims include incomplete medical records (29%), insufficient supporting claim data (24%), and coding errors (21%). Post-claim issues mainly stem from service episode problems (39%), coding errors (31%), and incomplete medical records (22%), originating from interconnected elements within the hospital's JKN claim management system, necessitating internal enhancements. The recommendations emphasize internal improvements, advocating for more effective socialization methods, updated communication practices, accuracy in diagnoses and procedures based on ICD, new outpatient medical record formats, and ongoing monitoring of electronic medical record progress. Additionally, it suggests appointing responsible medical staff, training the Medical Committee Chairperson, and advocating for budget allocation. Recommendations also target the Jakarta Provincial Health Office to enhance communication among healthcare providers and provide constructive feedback to align post-claim examinations with regulations. Lastly, it underscores BPJS Kesehatan's need to refine its application for improved feedback mechanisms to address JKN claim issues effectively.
B-2415
Depok : FKM-UI, 2024
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Ferawati Simbolon; Pembimbing: Ascobat Gani; Penguji: Kurnia Sari, Pujiyanto, Budi Hartono
Abstrak:
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Rumah sakit memiliki tujuan memberikan pelayanan yang merata tanpa memandang status ekonomi, untuk pemerataan pemberian layanan dan kemudian pemerintah membentuk JKN yang selanjutnya dikelola oleh BPJS kesehatan. Pasien peserta BPJS yang sudah dilayani akan dilakukan penagihan klaim kepada BPJS . Apabila berkas klaim yang diterima BPJS tidak lengkap maka pembayaran akan ditunda sampai rumah sakit melengkapi adanya kesepakatan antar rumah sakit dan BPJS. Penelitian ini merupakan penelitian observasional atau non-eksperimental dengan menggunakan metode kualitatif melalui telaah dokumen berkas klaim pending tahun 2021 dan wawancara mendalam terhadap informan yang bertujuan untuk memperoleh informasi mengenai faktor penyebab klaim pending di Rumah Sakit Ibu dan Anak Nabasa tahun 2021. Hasil dari penelitian ini adalah dari total 5380 klaim yang diajukan, ada 1599 kasus klaim pending. Dari hasil penelitian juga didapatkan ada tujuh faktor penyebab klaim pending dan tiga kasus terbanyak adalah resume medis tidak lengkap, koding tidak sesuai serta konfirmasi USG pada rawat jalan. Penyebab kasus klaim pending tersebut karena tidak ada pengecekan dahulu berkas klaim sebelum berkas tersebut diajukan, human error, serta petugas koder dan verifikator rumah sakit yang tidak kompeten.
The hospital aims to provide equal services regardless of economic status, leading to establishment of the National Health Insurance (JKN) managed by the Health Insurance Administration Agency (BPJS Kesehatan). Patients who are participants of BPJS will have their claims billed to BPJS after receiving treatment. If the claim documents obtained by BPJS are incomplete, the payment will be postponed until the hospital completes the necessary agreement between the hospital and BPJS. This research is an observational or non-experimental study conducted using qualitative methods through the review of claim document files pending in 2021 and in-depth interviews with informants. The goal is to obtain information about the factors causing pending claims at the Nabasa Mother and Child Hospital in 2021. The results of this study show that out of a total of 5,380 claims submitted, there were 1,599 cases of pending lawsuits. The research also identified seven factors causing pending claims, with the top three being incomplete medical resumes, incorrect coding, and lack of confirmation for outpatient ultrasound examinations (USG). The causes of these pending claim cases are attributed to the need for prior verification of claim documents before submission, human error, and incompetent hospital coders and verifiers.
B-2376
Depok : FKM-UI, 2023
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Rachmat Kamaluddin; Pembimbing: Wiku Bakti Bawono Adisasmito; Penguji: Pujiyanto, Helen Andriani, Eka Ginanjar, Hima Liliani
Abstrak:
Penyakit jantung iskemik dan stroke masih penyebab utama kematian di dunia dalam 15 tahun terakhir. Di Indonesia, penyakit kardiovaskuler meningkat seiring bertambahnya tahun.Penyakit kardiovaskuler juga berdampak kepada pembiayaan dimana berdasarkan data BPJS dari tahun 2014-2018 terus mengalami peningkatan baik dari jumlah kasus maupun biaya. Jumlah yang besar dalam kasus maka diikuti beban pembiayaan yang besar pula. Akibat dari defisit neraca keuangan tersebut, pembayaran klaim menjadi terhambat. Selain faktor defisit, faktor administrasi internal rumah sakit dan verifikasi BPJS juga menjadi penyebab klaim belum dibayarkan. penelitian ini bertujuan mengidentifikasi permasalahan dan solusi pada berkas klaim JKN yang pending di pusat jantung terpadu Rumah Sakit Cipto Mangunkusumo periode bulan Juli - Desember 2019. Desain penelitian yang digunakan adalah kualitatif dengan pendekatan studi kasus. Hasil penelitian didapatkan permasalahan yaitu resume tidak lengkap, pegawai multitasking, sumber daya terbatas, kesalahan distribusi berkas klaim, sistem informasi yang belum bisa mengakomodir kebutuhan, dan faktor eksternal dari BPJS kesehatan. Solusi yang dapat dilakukan adalah Meningkatkan komitmen dan prioritas, Membangun unit khusus pengelolaan pelayanan JKN, Menyediakan dan meningkatkan kemampuan SDM yang profesional dan handal, Menyediakan sarana dan anggaran yang memadai, Menerapkan sistem yang sederhana dan tegas, Membuat sistem informasi yang real time, transparan dan terintegrasi, dan Meningkatkan adaptabilitas terhadap respon external
Ischemic heart disease and stroke are still the leading causes of death worldwide in the past 15 years. In Indonesia, cardiovascular disease increases with increasing years. Cardiovascular disease also has an impact on financing, which is based on BPJS data from 2014-2018 which continues to increase both in the number of cases and costs. A large amount in this case is followed by a large financing burden. As a result of this deficit in the balance sheet, payment of claims was hampered. In addition to the deficit factor, internal hospital administration factors and verification of the BPJS are also the cause of claims not being paid. This study aims to identify problems and solutions in the JKN claim file that is pending in the integrated heart center of Cipto Mangunkusumo Hospital for the period July - December 2019. The research design used is qualitative with a case study approach. The results showed that the problems were incomplete resume, multitasking employees, limited resources, error in the distribution of claim files, information systems that could not accommodate the needs, and external factors from BPJS Kesehatan. Solutions that can be done are increasing commitment and priority, building a special unit for the management of JKN services, providing and improving the capabilities of professional and reliable human resources, providing adequate facilities and budget, implementing a simple and firm system, creating a real time, transparent and integrated, and improves adaptability to external responses
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Ischemic heart disease and stroke are still the leading causes of death worldwide in the past 15 years. In Indonesia, cardiovascular disease increases with increasing years. Cardiovascular disease also has an impact on financing, which is based on BPJS data from 2014-2018 which continues to increase both in the number of cases and costs. A large amount in this case is followed by a large financing burden. As a result of this deficit in the balance sheet, payment of claims was hampered. In addition to the deficit factor, internal hospital administration factors and verification of the BPJS are also the cause of claims not being paid. This study aims to identify problems and solutions in the JKN claim file that is pending in the integrated heart center of Cipto Mangunkusumo Hospital for the period July - December 2019. The research design used is qualitative with a case study approach. The results showed that the problems were incomplete resume, multitasking employees, limited resources, error in the distribution of claim files, information systems that could not accommodate the needs, and external factors from BPJS Kesehatan. Solutions that can be done are increasing commitment and priority, building a special unit for the management of JKN services, providing and improving the capabilities of professional and reliable human resources, providing adequate facilities and budget, implementing a simple and firm system, creating a real time, transparent and integrated, and improves adaptability to external responses
B-2170
Depok : FKM-UI, 2021
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Nilandari; Pembimbing: Kurnia Sari; Penguji: Pujiyanto, Puput Oktamianti, Andi Basuki Prima Birawa
Abstrak:
Keterlambatan pengajuan klaim BPJS berakibat pada turunnya cashflow rumahsakit. Proses klaim saat ini berjalan tidak efisien dan efektif. Tujuan daripenelitian ini adalah mendapatkan hasil analisis dan usulan perbaikan alur prosesdokumen klaim BPJS pasien rawat jalan dengan menerapkan konsep LeanHospital. Penelitian dengan pendekatan kuantitatif dan kualitatif inimengobservasi waktu yang dibutuhkan untuk menyelesaikan dokumen klaimsebelum diberikan kepada verifikator BPJS serta melakukan wawancaramendalam, observasi proses, dan telaah dokumen. Hasil penelitian menunjukkanterjadi waste terbesar di unit mobilisasi dana yaitu selama 32,5 hari 18,8 menitdalam penyelesaian dokumen klaim. Jenis waste terbanyak adalah waiting dantransportation. Berdasarkan VSM diketahui Lead Time dari proses klaim saat iniadalah 33,9 hari. Usulan perbaikan yang diberikan dari penelitian ini adalahdengan optimalisasi tim Casemix yang baru saja dibentuk, sehingga lead timepengerjaan klaim yang dibutuhkan menjadi 6,44 menit. Standardisasi kerja danpenilaian kinerja berupa KPI, IKI, dan IKU dinilai perlu diterapkan agar kinerjapetugas menjadi optimal.
Kata Kunci: Lean Thinking, BPJS, klaim, value added activity, non value addedactivity, waste
Delay in the submission of BPJS claims resulted in decreasing hospital cash flow. The currentclaim process is not efficient and effective.The objective of this reseach is to analize and proposeimprovement in the claim process by applying Lean Hospital concept. This research usedquantitative and qualitative approaches to observed the time required to complete the claimprocess before submitted to the BPJS verificator and also have an in-depth interview, observe theprocess, and document review. The result showed most waste happened in mobilisasi dana unitfor 32.5 days 18.8 minutes in the settlement BPJS document claims. Based on Value StreamMapping, Lead Time of the claim process at this time is 33.9 day. Most types of waste arewaiting and transportation. Proposed improvement provided from the study is to optimizing thecasemix team which newly formed. By optimizing the casemix team, Lead Time required tocomplete the claims process is 6.44 minutes. Standardize work and performance appraisal (KPI,IKI, and IKU) consider to apply to reach employee best performance.
Keywords: Lean Thinking, BPJS, claim, value added activity, non value added activity, waste
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Kata Kunci: Lean Thinking, BPJS, klaim, value added activity, non value addedactivity, waste
Delay in the submission of BPJS claims resulted in decreasing hospital cash flow. The currentclaim process is not efficient and effective.The objective of this reseach is to analize and proposeimprovement in the claim process by applying Lean Hospital concept. This research usedquantitative and qualitative approaches to observed the time required to complete the claimprocess before submitted to the BPJS verificator and also have an in-depth interview, observe theprocess, and document review. The result showed most waste happened in mobilisasi dana unitfor 32.5 days 18.8 minutes in the settlement BPJS document claims. Based on Value StreamMapping, Lead Time of the claim process at this time is 33.9 day. Most types of waste arewaiting and transportation. Proposed improvement provided from the study is to optimizing thecasemix team which newly formed. By optimizing the casemix team, Lead Time required tocomplete the claims process is 6.44 minutes. Standardize work and performance appraisal (KPI,IKI, and IKU) consider to apply to reach employee best performance.
Keywords: Lean Thinking, BPJS, claim, value added activity, non value added activity, waste
B-1795
Depok : FKM UI, 2016
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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Kresensia Nensy; Pembimbimbing: Sandi Iljanto; Penguji: Vetty Yulianty Permanasari, Kurnia Sari, Samsul Bahri
Abstrak:
Latar belakang:Besarnya selisih klaim BPJS RSUD Dr. Ben Mboi Ruteng Tahun 2016 dengan pembayaran Klaim oleh BPJS Kesehatan, yakni sebesar Rp. 5.038.707.422, mengganggu cashflow rumah sakit, dimana penerimaan rumah sakit 75% berasal dari pembayaran BPJS Tujuan:Penelitian ini bertujuan mendeskripsikan hubungan antara faktor kelengkapan resume medis, faktor ketepatan pengisian resume, faktor kelengkapan sistem informasi, faktor ketepatan sistem informasi pada berkas klaim BPJS pasien rawat inap di RSUD Dr. Ben Mboi Ruteng dengan pembayaran oleh pihak BPJS. Metode:Penelitian ini adalah penelitian kuantitatif dengan desain cross sectional. Sampel berjumlah 504 berkas klaim, yaitu berkas klaim dengan 5 kode INA-CBGs terbanyak. Pengumpulan data menggunakan pedoman checklist. Data terkumpul dianalisis dengan metode analisis univariat, bivariat, uji ChiSquare dan analisis multivariat uji regresi logistic. Hasil:Terdapat10,9% tidak lengkap resume medis, Terdapat 13,1% yang tidak tepat dalam pengisian resume medisnya. Terdapat 7 % berkas klaim tidak tepat sistem informasinya. Sedangkan kelengkapan sistem informasi tidak memiliki masalah karena semuanya lengkap sistem informasinya. Berdasarkan analisis bivariat, didapatkan hubungan bermakna pada kelengkapan dan ketepatan resume medis dan kelengkapan sistem informasi dengan pembayaran BPJS. Sedangkan kelengkapan sistem informasi tidak memiliki hubungan bermakna dengan pembayaran BPJS. Hasil analisis multivariat didapatkan ketepatan sistem informasi paling berhubungan dengan pembayaran BPJS. Kesimpulan: Terdapat hubungan yang bermakna antara kelengkapan [Type text] [Type text] [Type text] resume medis dengan pembayaran BPJS (hasil verifikasi), terdapat hubungan yang bermakna antara ketepatan resume medis dengan pembayaran BPJS (hasil verifikasi), tidak Terdapat hubungan yang bermakna antara kelengkapan sistem informasi dengan pembayaran BPJS (hasil verifikasi), terdapat hubungan yang bermakna antara ketepatan sistem informasi dengan pembayaran BPJS (hasil verifikasi). Kata Kunci : Berkas klaim BPJS Pasien Rawat Inap, Pembayaran BPJS Background: The magnitude of the difference in claims BPJS RSUD Dr. Ben Mboi Ruteng Year 2016 with Claim payment by BPJS Health, which is Rp. 5,038,707,422, disturbing hospital cashflow, where hospital admission 75% comes from BPJS payments Purpose: This study aims to describe the relationship between medical resume completeness factor, precision resume filling factor, information system completeness factor, accuracy factor of information system on claim file BPJS Of inpatients in RSUD Dr. Ben Mboi Ruteng with payment by BPJS. Method: This research is quantitative research with cross sectional design. The sample totals 504 claim files, which are claims files with the 5 most INACBGs codes. Data collection using checklist guidelines. The collected data were analyzed by univariate analysis, bivariate, ChiSquare test and multivariate analysis of logistic regression test. Result: There are 10,9% incomplete medical resume, There is 13.1% which is not proper in filling of medical resume. There is a 7% improper claim file for its information system. While the completeness of the information system does not have a problem because everything is complete information system. Based on bivariate analysis, there is a significant correlation on completeness and accuracy of medical resume and completeness of information system with payment of BPJS. While the completeness of the information system has no significant relationship with the payment BPJS. Multivariate analysis results obtained information system accuracy most related to the payment BPJS. Conclusion: There is a significant relationship between medical resume completeness and BPJS payment (verification result), there is a significant correlation between the accuracy of medical resume with payment BPJS (verification result), no significant relationship between the completeness of [Type text] [Type text] [Type text] information system with payment BPJS (verification result) , There is a significant relationship between the accuracy of information systems with payment BPJS
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B-1905
Depok : FKM-UI, 2017
S2 - Tesis Pusat Informasi Kesehatan Masyarakat
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